Provider Demographics
NPI:1598844771
Name:NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-922-4850
Mailing Address - Street 1:105 HALL ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2288
Mailing Address - Country:US
Mailing Address - Phone:231-922-4850
Mailing Address - Fax:231-935-3856
Practice Address - Street 1:105 HALL ST
Practice Address - Street 2:SUITE A
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2288
Practice Address - Country:US
Practice Address - Phone:231-922-4850
Practice Address - Fax:231-935-3856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0750910832OtherBCBSM OPC GRAYLING
MI0750910832OtherBCBSM OPC GRAYLING